Reversing the Tide of the Opioid Crisis

BWH investigators throughout the hospital are launching new research projects to combat the rise of opioid addiction and opioid-related deaths

Scott Weiner, MD, is studying how to make data from Prescription Drug Monitoring Programs more easily interpretable for physicians. Pictured on his screen is an example of an alternative interface for presenting commonly used PDMP data, such as pharmacy locations and overdose risk score, in a graphical format.

Massachusetts has been one of the hardest-hit states in the nation’s opioid crisis, with the rate of opioid-related deaths seeing a fourfold increase between 2000 and 2015. In the span of just one year, 2013 to 2014, opioid-related deaths occurred in two-thirds of cities and towns in Massachusetts, according to the state’s Department of Public Health. In 2014, the fatal overdose rate in Massachusetts was more than double the national average.

In light of these grim statistics, BWH clinicians and researchers across departments and divisions are working to find new ways to stem the tide of opioid addiction and opioid-related deaths. Brian Mullen, PhD, of the Brigham Digital Innovation Hub (iHub), and Scott Weiner, MD, MPH, of the Department of Emergency Medicine and director of the Brigham Comprehensive Opioid Response and Education (B-CORE) Program, are working to bring innovators together to share ideas and resources. They have collected information on more than a dozen BWH projects so far.

The following profiles are a brief snapshot of some of the projects to improve safety and mitigate risks for patients treated for pain at the Brigham and beyond.

Music to Your Ears, Soothing to Your Brain

Some music just makes a person feel good – literally. Listening to one’s preferred music has been found to activate the reward pathways in the brain with increased release of mood-enhancing neurotransmitters dopamine and serotonin.

Now, two toxicology experts at the Brigham are examining whether some types of music can make people feel so good that they are less inclined take to opioids after suffering an acute injury.

Edward W. Boyer, MD, PhD, and Peter R. Chai, MD, MMS, both of the Division of Medical Toxicology in the Department of Emergency Medicine, are co-principal investigators of a pilot feasibility study that combines machine learning, mobile devices and a music-based intervention to supplement conventional pain treatment.

“The first step toward addiction is exposure, and if I take a hundred people and put a psychoactive substance in front of them – whether it’s heroin, nicotine, caffeine or chocolate – there’s going to be a population that develops a compulsive use of that substance,” Boyer said. “Music therapy is a way of limiting the impact while adequately modifying the pain.”

Participants comprise patients in the Brigham’s Emergency Department (ED) observation unit who have been prescribed opioids for pain. Upon enrollment in the study, they are provided with an iPhone and are taught how to use an app called “Unwind,” Chai explained. Users are first instructed to place the smartphone on their chest, enabling the device’s biometric capabilities to capture the person’s heart rate. The app also asks users to indicate how relaxed they feel and how much pain they are in, using a standard 10-point scale.

Using those three inputs, a computer algorithm generates a brief instrumental piece. Once the song is over, users are asked again to rate their state of relaxation and pain. Boyer and Chai are studying changes in opioid ingestion patterns and opioid use while participants remain in ED observation.

Although still in the very early stages of enrollment, Chai said the team has already seen intriguing results.

With plans to enroll 60 participants, the team hopes their work will also have broader implications beyond opioid use. If successful, they said the results could be used to play music known to alleviate stress in areas of a hospital where patients and visitors are prone to anxiety, such as MRI scanners or infusion suites.

Making PDMPs More User-Friendly for Prescribers

Prescription Drug Monitoring Programs (PDMPs) are online databases that have been implemented in nearly every state in the U.S. to help clinicians improve safety by cataloging every patient’s controlled substance prescriptions. In Massachusetts, all prescribers are required to check the state’s PDMP, known as MassPAT (Massachusetts Prescription Awareness Tool), before writing a prescription for opioids.

It’s an important, effective tool in the face of the nation’s opioid crisis. But in practice, the presentation of data is simply not intuitive, explained Weiner.

With funding support from The Pew Charitable Trusts, Weiner and his team are studying how to make data from PDMPs more easily interpretable.

“The current layout shows you a list: prescriber, date, medication and other information like where the pharmacy is. That’s OK if there are one or two prescriptions, but if there are four or five, it becomes difficult for clinicians to make sense of everything in that format,” Weiner said.

Some risk factors aren’t as obvious when conveyed merely as text. One example is the geographical location of where patients are obtaining and filling opioid prescriptions, Weiner explained. When locations are shown on a map instead of as a list of addresses, it may be easier to see if a patient is “doctor shopping,” or attempting to illicitly procure prescription drugs by visiting providers at distant locations for the same event. The team is currently comparing more graphical interfaces and analyzing the data from their interviews with clinicians.

“The goal is to use what we learn to make recommendations to policymakers about how we all can improve these databases so that clinicians can interpret them more accurately,” Weiner said.

In a related, concurrent project through the MITRE Corporation, Weiner is performing a study at the Brigham with Jaya Tripathi, MS, a data analytics expert at MITRE, and BWH primary care physicians Karen Sherritt, MD, and Zoe Tseng, MD, to compare how well physicians can identify risk factors from the PDMP using either the standard version or a new, enhanced version implemented on a simulated PDMP website.

“In an ideal world, when I, as a prescriber, begin to write a prescription and hit the ‘sign’ button, this information should pop up in front of me in a clear, digestible format that I can interpret within 10 or 15 seconds,” Weiner said. “I should be able to see right there if the patient has a behavior that’s concerning, such as multiple prescribers or overlapping prescriptions – something that would make me think twice before prescribing an opioid.”

Helping Patients in Pain Navigate Their Treatment

For patients with complicated pain conditions, it’s not always clear what specialists they should see and in what order they should see them. Pain medicine experts led by Christopher Gilligan, MD, chief of the Division of Pain Medicine, have started a collaboration with the Program in Interdisciplinary Neurosciences to help ensure that patients who struggle with chronic pain conditions don’t get lost or bounced around the system, with little coordination among specialists.

“This may be the most important thing we can do for these patients,” said Gilligan. “And part of this touches on the opioid question: If we treat chronic pain with opioids, the risks may outweigh the benefits. Other critical components that could alleviate pain – including non-opioid pain medications, epidural steroid injections, physical therapy plans, mental health services and more – are often ignored, potentially contributing to our nation’s opioid epidemic.”

To guide patients to the most appropriate pain experts, Gilligan and colleagues have designed a Pain Navigator Program. Navigators, a newly created position, will be nurse practitioners with expertise in caring for patients with chronic pain and highly knowledgeable about all specialists and resources relevant to pain medicine across BWH. The pain navigator will help individual patients understand their various pain care options, secure timely appointments with appropriate specialists and advocate for the patient’s medical needs. Crucially, navigators will remain assigned to patients so that, if treatments are unsuccessful, subsequent care strategies can be readily pursued.

The team has designed a two-year, randomized clinical trial to evaluate if access to a navigator results in reduced opioid use, improved subjective scores of patient well-being and fewer visits/less use of services.

“We want to help address the opioid epidemic by getting patients in pain to the right specialists in the right place at the right time. We’re confident in our approach, and want to quantitively evaluate its benefit for our patients,” said Gilligan.

New Collaborations

Other investigators who are currently working on research projects related to the opioid crisis are encouraged to connect with iHub and B-CORE to learn more about the new initiative underway to bring the research community together around this topic. Learn more about B-CORE at http://bcore.brighamandwomens.org.